OF mental health care and mentally ill

Mental health and mental illness distinguish

This chapter has argued for mental health and mental illness distinguish. At present most policy and practice is based on the conflation of the two under the one referent ‘mental health’. In effect this conceptualizes the two on one continuum which I represent as a slide (as that is what people seem to fear) from mental health into mental illness.

What this means in practice is that people neither talk about mental health (qua health) as they think others are assuming that they are referring to mental illness; nor do they discuss mental illnesses, preferring instead to refer to them with the anodyne phrase ‘people with mental health problems’. Merely substituting the term ‘mental illness’ with this libertarian nomenclature does nothing to challenge the power of the medical/psychiatric model in this field, or to advance a critique of diagnosis, or to change the stigmatizing effect of mental illnesses and the general public’s attitude to them – exacerbated by the then British home secretary, Jack Straw, who consistently conflated ‘personality disorders’ with dangerousness – with serious (and dangerous) consequences for proposed changes to future Mental Health Acts, currently under review (see http://www.DH.gov.uk/ mentalhealth/summary.htm and http://www.DH.gov.uk/hspch/visped.htm Proposing a conceptual separation between the two terms may be represented by two continua, first advanced by the Canadian Minister of National Health and Welfare (MNHW) in 1988. There are a number of implications – and advantages – to this formulation:

Conceptual: As we know from our own experience that we can be ill and well at the same time (having a cold and feeling good, being physically ill and mentally healthy, etc.) and, as according to Euclidian physics, we cannot be in two places at once, so we need the concept of two continua to explain this aspect of our human experience.

Philosophical: By separating the two fields, the two continua concept opens up the possibility of dialogue between health and illness (which, in its onedimensional approach, the one continuum concept avoids). From this we can then engage in the debates advocated, albeit from their different perspectives, by Fox (1999) and Suzuki (1999). In considering the relationship between the two, Duff (1993) reminds us of the value of illness to health: ‘illness is to health what dreams are to waking life – the reminder of what is forgotten, the bigger picture working toward resolution’ (p. 33). Illness as metaphor, the ‘healing crisis’ familiar to complementary health practitioners, the significance of subjectivity and the concept of arché-health – ‘the condition of possibility for health and illness– are all examples of the complex interrelationship between illness and health.

Practical: It is only possible to promote the mental health of the mentally ill (as The Health of the Nation (DH 1992) first proposed) if we advance the two continua concept (else they are left languishing at the ill end of the one continuum, with no possibility of health). Some forms of occupational therapy, self-development courses, a women’s conscious nessraising group, patients’ meetings, all within the psychiatric setting, and involving users in their diagnosis and treatment and in the planning of services – are all examples of mental health promotion of the mentally ill and all depend on the view that, while having a diagnosed mental illness or disorder, they also have mental health which can be promoted and enhanced. This approach also addresses the critical comment the Standing Nursing and Midwifery Advisory Committee (1999) made in a report on mental health nursing, admitting that ‘users have no real role in designing and implementing professional education and training’.

Clinical: The two continua concept is congruent with the multi-axial diagnostic approach taken by the Diagnostic and Statistical Manual of Mental Disorders-IV-TR (American Psychiatric Association 2000) (an approach adopted in the revision of its third edition in 1987). This multi-axial system proposes five axes or continua which in effect describe a holistic approach to diagnosis:

Axis I: Mental disorders

Axis II:Development disorders Personality disorders

Axis III:Physical disorders and symptoms

Axis IV:Severity of psychosocial stressors

Axis V:Global assessment of functioning

It is a short logical step to propose a sixth axis on mental health and, even more radically, to propose in addition, a dialogic approach to each axis, thus:

Indeed this could almost define the role of the mental health nurse in mental illness diagnosis, treatment and care and in mental health care and promotion.

Pragmatic – the two continua concept can be (and has been) viewed as pragmatic: it claims mental health for all while not necessarily challenging the authority or territory of psychiatrists or mental ‘health’ professionals. In this sense the concept may be welcomed by already overworked practitioners in this field with some relief that they do not have to ‘do’ or ‘take on’ mental health promotion.

Political – on the other hand, claiming mental health for all may also be viewed as highly political, as the logic of promoting the mental health of the mentally ill may well involve other (non-psychiatric/mental ‘health’) professionals and lay people, as it were, breaking into the asylum. At one point in the ‘Italian experience’ of mental health reform, psychiatric patients and staff in Trieste built a wooden horse (called Marco) which, in the same way that its Ancient Greek counterpart was taken into the city of Troy (only later to reveal its contents), was also paraded around the streets of the city. The approach to mental health promotion advocated in this chapter and other similar work might well be viewed as a subversive ‘wooden horse’: this time putting sanity into the mental hospital and, indeed, seeing sanity in and alongside madness.